www.ProHealth.com • November 26, 2003
By William B. Salt II
WebMD Live Events Transcript Archive
Moderator: Welcome to WebMD Live. Today we will be discussing Fribromyalgia with William B. Salt, II, M.D., and Edwin H. Season, M.D.
William B. Salt II, M.D., is board-certified in both internal medicine and gastroenterology. He received his M.D. degree from The Ohio State University in Columbus, Ohio, in 1972, where he currently holds an appointment as Clinical Associate Professor in Medicine. He trained for five more years in internal medicine and gastroenterology at Vanderbilt University Hospitals in Nashville, Tennessee, where he also served as a Chief Resident in Medicine.
Edwin H. Season, M.D., is board-certified in orthopedic surgery. He received his M.D. degree from The Ohio State University in Columbus, Ohio, in 1971, followed by internship at the University of Virginia. He then returned to Ohio State for his residency and upon its completion, taught orthopedic surgery as an assistant professor in The Ohio State University College of Medicine from 1976 to 1980.
Dr. Salt, Dr. Season, welcome back to WebMD Live. What is fibromyalgia?
Dr. Season: Fibromyalgia is wide-spread muscular aching pain and stiffness, associated with tenderness on palpation of characteristic paired sights called trigger, or tender points located in the neck, the back, and the extremities. Fibromyalgia, in addition to having widespread muscular pain, also has fatigue, a sleeping disorder, and some type of stress-anxiety and depression.
Moderator: What causes it?
Dr. Salt: Fibromyalgia is considered to be a functional illness, so the symptoms are real and not imagined, and the medical tests are normal. Most patients and doctors view and understand fibromyalgia and related functional illnesses through what we call a bio-medical model, that fails to explain illness where there is no evidence of disease. The model is based upon “reductionism,” where all problems can be explained A to B, cause and effect, and based upon dualism, that the mind and body are split and separate.
But the reality is, all illness is multi-dimensional. In other words, fibromyalgia and other functional illnesses can really be understood through what doctors call a biopsychosocial-spiritual model. Dr. Season and I propose that people, patients and doctors, need to use a common language to understand the cause of fibromyalgia, and how to feel better with it. It’s important then to understand that the functional illnesses like fibromyalgia are best addressed by recognizing, understanding, and accepting the connection of body, mind and spirit, the inter-relationships of body, mind, and spirit with genetics, environment, and society, and the impact and influence of conscious as well as unconscious mind, though, and motion and stress.
Moderator: Are the symptoms all in the head?
Dr. Salt: The symptoms are not all in the head, but they are in the mind-body-spirit. The organ in the head, the brain and the mind, is connected to the body, and we know this through the spinal cord connection, through the autonomic nervous system, and through the neuropeptide messenger communication system, that is, small protein molecules that circulate through the body and communicate messages back and forth between brain and body and vice versa. So we know that we have to look at the mind-body, and really the spirit, from a holistic perspective to begin to understand that the symptoms, though real, cannot be explained through a bio-medical model which looks at body only.
We believe there’s a relationship between fibromyalgia and an abnormal reaction to stress, or an abnormal stress response. Stress can be defined as the perception of a physical or psychological threat, and the perception of being ill-prepared to cope with that threat. Anytime an individual is undergoing excessive stress, that can be a contributing factor to fibromyalgia. Remember 2 things about stress — the first is that stress is perceptual. One person’s poison is another person’s potion. Second, the perception of stress may be occurring at an unconscious mind level, so we may be unaware that we’re under the stress from a cognitive perspective.
Moderator: Why do people get fibromyalgia?
Dr. Season: There are a number of factors, and stress is just one factor. What we have found is that fibromyalgia patients commonly have a sleep disorder, and they commonly are deconditioned, or out of condition. From that standpoint, we feel that these factors are associated with the development of fibromyalgia. Whether the condition of fibromyalgia produces the sleep disorder or the deconditioning, or vice versa, the sleep disorder and the deconditioning produces fibromyalgia, we just can’t be sure… but there is a strong association. There are other factors as well.
Moderator: What does “fibromyalgia” mean? Where does the word come from?
Dr. Season: “Fibro” means fibrous tissue, and fibrous tissue is part of the connective tissues that hold the body together in the muscular-skeletal system. “Myalgia” means painful muscles, and all patients with fibromyalgia have widespread muscular pain.
Moderator: Is it commonly misdiagnosed?
Dr. Season: Yes, it’s commonly misdiagnosed, although there are accepted criteria for making the diagnosis, and physicians who have an interest in fibromyalgia should be able to make the diagnosis reasonably readily.
Moderator: How is fibromyalgia related to Irritable Bowel Syndrome?
Dr. Salt: Fibromyalgia and IBS are what doctors call functional illnesses, and the word or term “functional” means the symptoms are real and not imagined, but when medical tests are conducted such as x-rays, or endoscopies, or biopsy, or laboratory tests, the tests turn out to be normal. This can be very frustrating for both patient and doctor. There are actually many functional illnesses; fibromyalgia and IBS are two of the more common. Most of the symptoms that bring people to doctors today can’t be explained by medical testing. Other examples are tension headache, non-cardiac non-heart-related chest pain, chronic fatigue, and interstitial cystitis.
Many patients have more than one, and often several functional illness diagnoses. Scientific studies do confirm that 30 to 70% of patients diagnosed with fibromyalgia also have IBS, and that 30 to 70% of patients diagnosed with IBS also have fibromyalgia. The relationship is that functional illnesses are rooted in the biopsychosocial-spiritual… or mind-body-spirit model. Another common condition that’s a functional condition like these is jaw pain. Or temporal joint pain.
Moderator: How can information about the MindBodySpirit help solve the symptoms?
Dr. Salt: We feel strongly that the most important element for people and patients with fibromyalgia, IBS, and other functional illnesses, is knowledge and understanding, that it is important to understand and accept the mind-body-spirit connection. We feel that everyone, people, patients and doctors, tend to underestimate our individual power to heal. We feel strongly that treatment and healing are not the same; treatment is the application of something external, or something given to the patient, often by a doctor but even a natural substance like an herbal preparation…. but healing, by contrast, comes from within.
We believe that people and patients who suffer with these conditions, tend to underestimate their own power to heal and that they are more powerful than we all give them credit for. Neuropeptides can be turned on and off through thought, belief, relaxation, exercise, diet, sleep, and medication. And so in an effort to heal patients with fibromyalgia, improved health habits that involve exercise, proper diet, good sleep, and medication, specifically anti-depressants, can be beneficial.
stinger251_WebMD: Is there any connection between hypothyroidism and fibromyalgia?
Dr. Season: There’s no known relation between hypothyroidism and fibromyalgia.
MAMAJOY_WebMD: Have studies been done to show that “HSP’s” or “highly sensitive people” are more likely to suffer from FMS?
Dr. Salt: The prevailing concepts of what underlies fibromyalgia and IBS include a very important issue, which is that something is occurring at the level of the mind-brain, such that the individuals who suffer with symptoms of fibromyalgia and IBS have an increased sensitivity to stimuli, and the stimuli may be subtle stimuli, that is something eaten that would not ordinarily cause the stress or discomfort to someone who is considered to be “normal.” But we believe that there is an alteration at the level of mind-brain so that sensitivity is increased; in the field of digestive medicine, we call this “enhanced visceral” sensitivity. That mechanism of enhanced bodily sensitivity seems to be operating in fibromyalgia as well.
That is why Dr. Season had emphasized the stress issue, since it’s thought that stress both operating at a conscious and unconscious level, are at least contributing if not causing the alteration of sensitivity. Highly sensitive people, the term, is probably a label much like the labels of IBS and fibromyalgia.
Dr. Season: What Dr. Salt is talking about is actually abnormal pain processing. That’s very closely related to an abnormal stress response, and this can be at a conscious or unconscious level.
CntLQQKbck_WebMD: I was dx w/ Lupus and Fibromyalgia at the same time, and this just following a very traumatic, emotionally stressful time in my life. Is there a connection? If so, will I ever be able to go back to my “old” self again?
Dr. Salt: That brings up two very important issues; the first is that it’s very common for people and patients who suffer from functional illnesses such as fibromyalgia and IBS to report the onset of their condition and symptoms in conjunction or related to some kind of stress, be it physical or psychological stress or strain. The second is that it’s also common to have fibromyalgia in association with, or concurrent with another organic condition, and I think it’d be appropriate for Dr. Season to address that.
Dr. Season: Functional symptoms can be associated with organic arthritic conditions that are considered diseases; fibromyalgia is considered an illness. Rheumatoid arthritis, lupus, are considered diseases. The two can go hand in hand, and if an individual presents with functional symptoms, the physician has the responsibility to be sure to check for all types of actual organic diseases.
Dr. Salt: It would be therefore possible, to have a very mild case of lupus, and have most of the symptoms occurring related to fibromyalgia, so that if treatment were directed to the very mild form of lupus, one could see that very potentially strong or even toxic medications could be given in an effort to relieve symptoms that would be better relieved by directing towards fibromyalgia.
Fibromyalgia commonly occurs with other disease processes, and may be the primary producer.
Dr. Season: In addition to that, the types of treatments and healing that we recommend for fibromyalgia, are usually simpler and safer treatments than for more serious conditions such as lupus. Oftentimes it makes sense to go with the simpler approach first.
MAMAJOY_WebMD: How do you suggest using Mind/Body/Spirit to help the pain?
Dr. Salt: We feel that it is a matter of becoming conscious, or aware of the relationship of the mind-body-spirit connection, rather than simply looking at the words, truly becoming conscious of this connection. This consciousness may require considerable effort, and may require some study, in order to integrate the knowledge of it into the belief system, that this connection is very real. This consciousness of this connection, can bring relief in and of itself, but it’s the first place to start. So it requires good information and knowledge to begin this healing process.
A rather simple, practical approach using mind-body-spirit is to start an individual with fibromyalgia on a simple exercise program, and even though this seems like just a prescription of activity as opposed to anything that has to do with mind and spirit, the exercise program will produce benefits, particularly with respect to stress management.
Dr. Season: I think all of us on aerobic exercise programs understand how the aerobic exercise helps us to manage our stress. In addition to that, it also deals with one of the other problems associated with fibromyalgia, the sleep disorder. That is, exercise will encourage deeper sleep, more stage 4… which is the sleep that is deficient in a fibromyalgia. Just the simple exercise program will then help in terms of the stress and also help in terms of the sleep disorder.
Moderator: What are some ways to use diet and exercise to help and what are some specific foods that help or harm the body to this extent?
Dr. Season: I think the first rule of exercise is to start gradually and to progress gradually. Patients with fibromyalgia generally are deconditioned, and they find exercise challenging, painful, and difficult to initiate. I often recommend that patients with fibromyalgia start with a water exercise program, but any type of program that is not too strenuous and is progressed gradually is satisfactory.
Dr. Salt: It is important to include diet in any type of self-care plan. While we don’t have time to pursue matters of the specifics of diet, we obviously need to be thinking in terms of a low-fat, relatively plant-based diet with plenty of fruits and vegetables, as a start. There are modifications and variations of diet; it doesn’t mean you have to be a vegetarian and eat no meat, but we do need to look at the types of foods we eat, and the amounts we eat.
Being overweight is not healthy for any of us, particularly if we have a painful muscular-skeletal condition like fibromyalgia. Caffeine can be a problem; it’s a stimulant and can potentiate the stress response to any stressor that may be perceived or experienced, so it may be helpful to remove caffeine from the dietary regimen, for at least 2 to 4 week trial period, to determine if it might be beneficial.
Dr. Season: Chapter 28 in our book is entitled “Weight”, and we have information on the body mass index, which is the best way to determine ideal weight for an individual. If indeed the fibromyalgia patient can manage the weight problem in such a way to achieve ideal weight, that will help in terms of the overall feeling of the patient, and particularly will help self-esteem which is important. That along with the regular exercise program will bring benefits.
MAMAJOY_WebMD: We have a group that uses AA’s 12 step program for helping deal with chronic pain and illness. How do you feel about this?
Dr. Salt: The AA program is a very strong, very valid, very helpful program for dealing with all types of problems. This is a spiritually based program as well. My personal response would be that it could be very helpful.
stinger251_WebMD: Is severe upper arm muscle pain characteristic of fibromyalgia?
Dr. Season: Upper arm pain associated with pain at the neck and upper back is common in fibromyalgia. I think this is a good time to distinguish between fibromyalgia and myofascial pain syndrome.
Myofascial pain syndrome is regional muscular pain involving the shoulders, but it can be any region of the body… and it’s associated with stiffness and a tender point. However, it’s different from fibromyalgia in that usually the other components of fibromyalgia, that is the rather profound fatigue, difficulty sleeping, and the stress, anxiety, and/or depression problems are not present with myofascial pain. Both pain problems, that is those of myofascial pain and fibromyalgia pain, are treated in a similar manner. However, with fibromyalgia, attention has to be directed towards the fatigue, sleep disorder, and stress, anxiety, depression.
Moderator: What is the diagnosis of myofascial pain syndrome and what treatments are there?
Dr. Season: With respect to treatments and healing that are directed at the muscular pain, the medical approach is the same. However, with fibromyalgia, there are other conditions that need to be addressed as I mentioned.
Moderator: What proven methods are there to heal through diagnosis and education?
Dr. Season:
I think that it’s important to understand that the physician is very important in terms of making the diagnosis of fibromyalgia. There are criteria that are used and need to be satisfied for making the diagnosis, specifically those established by the American College of Rheumatology, and doctors should be involved in the diagnosis so they evaluate the patient and rule out other conditions that may mimic fibromyalgia.
However, the doctor generally has only a short period of time to evaluate and treat the patient; oftentimes it averages 10 minutes, and that doesn’t allow him to fully understand the patient’s condition, and to embark on a comprehensive treatment program. From that perspective, the patient has to shoulder some responsibility herself/himself, and 90% of patients with fibromyalgia are women.
There are 10% of the patients who are men, and from that standpoint, the patient has to become educated hopefully through reputable resources, and we consider our book to be a reputable resource, and then through knowledge and an understanding of a good holistic health habit; the patient can make progress in dealing with the symptoms.
Dr. Salt: A recent article in the annals of behavioral medicine entitled “A Meta of Fibromyalgia Treatment Mechanisms”, 1999 vol 21 pp 80. Non-pharmacological, or non-drug treatments, specifically cognitive behavioral therapy, and that would be realizing that the way we think about ourselves and about our symptoms will influence how we feel, and exercise, preferably aerobic, should be prescribed to help manage fibromyalgia symptoms and daily functions. Medications including anti-depressants and muscle relaxants can be used for sleep and pain symptoms, but its important to stress the power of non-pharmacological treatments, including information and good health habits.
MAMAJOY_WebMD: How does heredity factor in?
Dr. Season: Fibromyalgia is not thought to be inherited; there’s no hard evidence of a genetic predisposition. However, multiple members within a family may be diagnosed as having fibromyalgia.
suebe_05_WebMD: How do we overcome the fatigue with fms? have had it for 9 yrs dx and symptoms 20+. I am worse today than last year. How do I regain energy?
Dr. Season: Fatigue is the major disabling characteristic of fibromyalgia, and we believe that it is a reflection of the sleep disorder and the deconditioned status of the patient with fibromyalgia. Probably the best theoretical approach would be to initiate and progress an exercise program, preferably an aerobic exercise program. Exercise is known to improve levels of energy, and will also enhance good sleep and we know that when patients improve their sleep, they have more energy to get through the day.
Dr. Salt: It would be important to take a look at the diet, and make certain that we are eating a well-balanced diet with adequate nutrients and protein. That we realize the power of thought and belief on how we feel and the illness experience. And that we do not underestimate our ability to overcome this.
Dr. Season: We also need to appreciate the value of relaxation techniques, and meditation in terms of managing stress and improving energy level.
sandilb_WebMD: If stress is a major factor in fms, can I assume that as the stress is resolved, so will my fms symptoms.
Dr. Season: As I mentioned previously, widespread muscular pain, fatigue, difficulty sleeping and stress, anxiety and/or depression, are symptoms and conditions associated with fibromyalgia, and since we’ve commented about an abnormal stress response, it’s particularly important. It’s one thing to recognize that there is stress, it’s another thing to manage the stress. All of us are challenged by managing stress. If one can make changes in health habits, improve diet, maintain an ideal weight, there’s no doubt in my mind that the stress factor will be managed, and the fibromyalgia will be under better control.
Dr. Salt: To illustrate the mind-body relationship and the expression of stress and emotion into the body, one of the administrators at my hospital shared an interesting observation; she said, “When I’m under stress, I have a numbness and tingling that occurs in my left arm between my elbow and my wrist.” I thought that was fascinating and evident of the mind-body connection. But then she added, “And I have learned that I may not be actually aware that I am under stress at the time. I may not actually feel stressed at the level of my mind, such as anxiety. I have become aware that when that physical symptom occurs, that I am under strain and then I become aware of that strain.”
This brings us back to one of the points Dr. Season and I would like to emphasize. We all experience stress and emotion expressed in the body, and that stress and emotions occur at the conscious and unconscious level. It is not a weakness or mental illness to have the expression of stress and emotion in the body.
MAMAJOY_WebMD: Are the hundreds of lumps in my arms and legs due to FMS or MPS?
Dr. Season:The lumps you are describing are probably are fibromyalgia trigger or tender points. In order to officially be diagnosed as having fibromyalgia by the American College of Rheumatology criteria, you must have greater than 10 out of 18 trigger points on the body. Those trigger points can be treated with various approaches. For example, massage can be quite helpful for a trigger point. In my practice, I will inject a trigger point and when I do that, I will use a syringe or needle, and local anesthetic, and usually that can bring on some relief of those trigger points. Probably the best treatment for the widespread pain and trigger points, as I mentioned previously is regular exercise.
Dr. Salt: Our book is entitled Fibromyalgia and the MindBodySpirit Connection; we have broken the book down into 7 steps.
The steps are: 1, connecting mindbodyspirit. 2, learning about fibromyalgia and myofascial pain. 3, healing with diagnosis and education. 4, making the connection.5, emphasizing self-care and wellness. 6, managing your fibromyalgia. 7, taking action if symptoms persist.
The book can be obtained by calling 1-888-599-6464. And it is available on the internet at www.parkviewpub.com. It will be available in bookstores on a widespread basis within the next month or so, and locally within a bookstore. The official publication date is only this month, and can be obtained now at the telephone number and website.
Dr. Season: We feel that our book merges the best of scientific medicine with the best of natural and holistic healing. Our book recognizes the value of the physician as the facilitator and teacher, rather than the controller or primary manager of treatment.
We’re really interested in the patient taking control of fibromyalgia. The physician is, however, essential for making the diagnosis by proper criteria, and ruling out other conditions that can mimic fibromyalgia. The physician is necessary for writing the prescription for medication and specifically, anti-depressants when necessary to help enhance sleep. The physician is the primary educator and teacher for the fibromyalgia patient. However, other resources… our book, support groups, websites, are helpful in terms of supplying additional information.
The physician can provide valuable feedback and direction for the patient during treatment and healing. We also feel that our book recognizes the power of the patient in gaining knowledge about fibromyalgia and healing. Hopefully the book is a good source for that knowledge. Most importantly, our book emphasizes the patient’s role in self-care and wellness.
Dr. Salt: Dr. Season and I have been frustrated in attempting to explain functional illnesses in patients in the very brief time allotted in the current medical environment; in the range of 7 to 10 minutes, to help patients understand the complexity, in that most doctors and some patients do not think in terms of mind-body-spirit connection and use that kind of language. We feel that patients need to have a scientifically-based resource which helps patients and doctors understand the biopsychosocial-spiritual mind-body-spirit healing approach. We feel our book is the only current resource that provides this.
angel49_WebMD: What if your doctor tell you that there is absolutely nothing you can do for fibromyalgia?
Dr. Salt: It’s essential to find a doctor in whom you have confidence and where there is optimism. We can heal, we all have the potential to heal, and the relationship as Dr. Season pointed out, is important, almost magical in facilitating the healing.
Dr. Season: You may want to search for a support group in your neighborhood. Often the patients in support groups can provide resources for knowledge for fibromyalgia, and can direct you to the most knowledgeable and sympathetic physicians, as well as other caregivers on the team for treating fibromyalgia.
Moderator: Is there a cure for fibromyalgia? Are there cases where patients returned to “normal?”
Dr. Season: I don’t believe there is a cure for fibromyalgia. I think fibromyalgia is a condition that can be managed adequately, and I believe that the patient has to seek out the proper resources to become educated about fibromyalgia, as well as finding the right physician and caregivers.
Dr. Salt: Fibromyalgia, like health, requires the active application of a plan for living. Health is not the absence of disease and living; it requires an active pursuit and process of being healthy. When one has an illness such as fibromyalgia or IBS, that becomes even more important.
Dr. Salt: Dr. Season and I are very grateful for the audience and the time each has taken time out of their busy lives to be with us tonight. We want everyone to know that there are many doctors who care about them, and that they have the potential to heal. We all do, and we are optimistic that they can be successful. They need a new way of thinking and understanding, but perhaps we all do. But we’re grateful for the audience tonight. 888-599-6464 is the number for the book, and the website is: www.parkviewpub.com.
Source: WebMD. Copyright (c) 1998 1996 – 2001, WebMD, Inc. All rights reserved.http://www.webmd.com/.
NOTE: I have not read the book, and do NOT advocate any New Age practices.